53 - Surgical Treatment of Tailor's Bunion Deformities

Question 1

Conservative treatment

Answer 1

• Debridement of hyperkeratotic lesions
• Padding
• Shoe gear modifications
• NSAIDS
• Physical therapy (not that effective)
• Injections
• Orthoses (if it is a functional deformity)

Question 2

Surgical treatment

Answer 2

• Exostectomy (removing the bump)
• Arthroplasty (removing 5th metatarsal head)
• Osteotomies (Capital, Shaft, Basilar)

Question 3

Exostectomy

Answer 3

• Rarely Curative
• Low Level of Technical Difficulty
• Benefit is that it does not require any bone healing (like an osteotomy wound)
• There is only soft tissue healing that needs to take place
• Works well for geriatric patients that are just having irritation over the bump

Question 4

Arthroplasty

Answer 4

• Last resort joint destructive procedure where you simply remove the 5th metatarsal head
• This is used when the patient previously has had an implant that has failed
• Retraction of toe is one of the complications of this
• Does NOT require bone healing, similar to the exostectomy (soft tissue healing only)
• Consider this procedure for the same patient population (geriatric patients)
• If the patient has plantaflexion of the 5th ray with a large callus under the 5th metatarsal head this can work to reduce the pressure

Question 5

Capital osteotomies

Answer 5

• Hohmann
• Reverse Wilson (same as the Wilson done on 1st metatarsal for a bunion)
• Chevron (V osteotomy, also called a mini or reverse Chevron since it is also done on 1st met)
• Mercado

Question 6

Hohmann osteotomy

Answer 6

• Transverse osteotomy of metatarsal neck
• Fixation (difficult osteotomy to fixate internally)
• Recall that transverse fractures are most stable – same idea with a
  transverse osteotomy, the problem is that it is the most difficult to fixate
• ***Complications: under-correction, delayed or non-union, transfer lesions
• A transfer lesion is when you remove bone where there was a pressure callus, so the pressure is just redistributed to a different metatarsal and they develop a callus there instead
• The delayed or non-union would be a result of the difficulty fixating a transverse osteotomy

Question 7

Reverse Wilson osteotomy

Answer 7

• Oblique osteotomy is performed on the 5th metatarsal,
  running distal lateral to proximal medial
• This procedure is very similar to the Hohmann, but the
  cut is made obliquely for easier fixation
• Considered to be a modified Hohmann by Sponsel
• Fixation is still difficult since the 5th metatarsal is so narrow,
  it is hard to get a good oblique cut and still difficult to fixate
• Complications are the same as a Hohmann since the oblique
  cut may or may not be effective in reducing fixation concerns

Question 8

Chevron osteotomy

Answer 8

• Also called a “mini Austin” (similar to Austin done on the 1st metatarsal for a bunion)
• This is “pretty stable” overall – very stable in the sagittal and frontal plane because of the V construct, but not as stable in the transverse plane so we can move it into a correct position
• Fixation is very easy for this procedure
• One of the most common procedures for a Tailor’s bunion
• Complications

Question 9

Mercado osteotomy

Answer 9

• Distal Closing Wedge in Subcapital Bone With Apex Proximal Lateral
• Increased Technical Difficulty (“they’re a pain in the butt”)
• Easy to fixate, but the fixation is often prominent and eventually needs to be removed
• The diagram shows that this is a transverse wedge osteotomy with the apex laterally in
  the region of the neck of the 5th metatarsal
• Fixation is done in an oblique fashion, which creates somewhat of a “hinge” in the bone
• ***Complications: Hinge Fracture, Fixation Failure/Retrieval
• Hinge fracture is where the site of the wedge osteotomy and oblique fixation fractures

Question 10

STUDY: Cooper, M.T., & Coughlin, M.J. (2013). Subcapital OBLIQUE OSTEOTOMY for correction of bunionette deformity: Medium-term results.

Answer 10

• Level IV – retrospective case series with 16 feet in 14 patients
• 88% have good or excellent clinical result
• 88% had no limitation in activity
• VAS 1.6/10
• Small sample with short-term follow-up (2.9 years)

Question 11

Yancey

Answer 11

• Closing wedge at metatarsal shaft (instead of the neck of the 5th metatarsal, like the Mercado, the wedge is taken at the metatarsal shaft)
• Increased Technical Difficulty (similar to the difficulty of the Mercado)
• I don’t have any pictures of the Yancey because I don’t know why you would ever do it
• Fixation concerns are the same as the Mercado – but since this is at the mid-shaft, the fracture is even more of a concern because mid-shaft fractures typically do not heal great
• NWB is a major downfall – all other distal procedures for Tailor’s bunion is WB after surgery
• Complications are the same as the Mercado – hinge fracture, fixation failure, fixation retrieval, non-union, delayed union

Question 12

Gerbert

Answer 12

• Basilar closing wedge of the base of the 5th metatarsal
• I am only aware of one person who does a Gerbert osteotomy – Gerbert himself
• Increased technical difficulty because it is a wedge osteotomy
• Healing concerns have been raised (same idea as a Jones fracture – watershed area),
  so this deters a lot of surgeons away from this procedure
• Fixation is Gerbert’s justification for this procedure (it will heal because of the fixation…
  We know that Jones fractures heal much better with fixation than without)
• NWB – major downfall, all proximal procedures will require this
• Complications: delayed healing (due to watershed area)

Question 13

WHAT TO KNOW

Answer 13

• Be able to identify the different anatomical locations of each of the procedures
• Example: All of the following are capital osteotomies except…
• Example: The Gerbert ostotomy is made in which region of the bone?
• I may ask you some questions about the fixation issues
• Example: oblique closing wedge of the 5th metatarsal is more complicated because… Hinge fracture, fixation failure, etc
• Don’t have a lot of text on the slides, should not be that difficult